Effective communication is an essential component of patient-centered care. Emerging evidence suggests that favorable organizational communication, or the health communication practices within and between constituents of a healthcare system, is essential to the delivery of high quality, reliable and safe patient- centere care. Advancing research to determine the relationship between organizational communication and patient outcomes is necessary and critical to promote the integration of communication assessment into routine health system self-evaluation and quality monitoring. The goal of this proposal is to advance the assessment and understanding of the practices, determinants and associated patient outcomes of health- related organizational communication practices. End-stage renal disease (ESRD) and the provision of life- sustaining dialysis treatment provides a unique and robust environment to examine dialysis facility organizational communication and its impact on patient outcomes. Patients with ESRD are at significantly higher risk for mortality, hospitalization, and poor quality of life. Despite advances in the technology of dialysis care, outcomes are persistently poor indicating opportunities for novel strategies to improve patient healthcare. Overall, we hypothesize that organizational communication contributes significantly to individual patient outcomes, facility-level quality metrics, and also may overcome disparities in outcomes among vulnerable patient populations. As part of this proposal we will leverage the resources of the Dialysis Outcomes and Practice Patterns Study (DOPPS), a representative prospective international cohort study since 1996, in 21 countries, aimed to identify modifiable practices associated with improved patient outcomes. To address our hypothesis, the aims of this proposal are: 1) To characterize the quality of organizational communication in dialysis facilities by adapting, administering and validating an existing measure in 100 facilities and 700 hemodialysis patients; 2) To examine in a prospective cohort the association of organizational communication with clinical and patient-reported outcomes in 465 dialysis facilities and 15,000 patients worldwide; and 3) To determine if dialysis facility organizational communication modifies associations of age, race, or health-literacy related disparities and clinical or patient-reported outcomes. We are an integrated, diverse research team well equipped and uniquely poised to efficiently leverage existing infrastructure to significantly advance health communication research. Importantly, we are also connected to a deep network of national and international resources to ensure dissemination of our findings to a broad audience. This research will serve future research by advancing methodology of communication assessment and also our understanding of mechanisms of organizational communication in dialysis care. Most importantly, this research will inform the future development and testing of efficient and effective multi-level interventions to connect patients, providers and health systems to optimize quality programs and patient-centered care.